Provider Demographics
NPI:1114633542
Name:KOCH, MICHELE ANNETTE (PT, CLT-LANA, WCC)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:ANNETTE
Last Name:KOCH
Suffix:
Gender:F
Credentials:PT, CLT-LANA, WCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 FERN RDG
Mailing Address - Street 2:
Mailing Address - City:FELTON
Mailing Address - State:CA
Mailing Address - Zip Code:95018-9028
Mailing Address - Country:US
Mailing Address - Phone:831-419-4883
Mailing Address - Fax:
Practice Address - Street 1:2045 40TH AVE STE A
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-2549
Practice Address - Country:US
Practice Address - Phone:831-465-7988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32101225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist